Translating Evidence Into Practice: System-Centered Implementation Strategies

Week 1Week 1IntroductionIntroduction

Laura Schmidt, Ph.D, MSW, MPHJim Kahn, MD, MPH

Philip R. Lee Institute for Health Policy Studies

Clinical and Translational InstituteTraining in Clinical Research Program

Roadmap for today’s introductions

• This Course

• T2 Translational Research

• Organizational Theory at the Systems Level

Introduction: PART 1Introduction: PART 1

THIS COURSE

Your Fearless Leaders

PART ONE:Introduction to systems change

TODAY: Introduction to T2 Research Organizational Environments

WEEK 2: Policy Implementation

WEEK 3: Changing Systems

PART TWO :Selected tools for systems-level change

 DATE SPEAKER TITLE

4//21   Hal Luft Redesigning Benefits Structures: Health Coverage

4/28   Michael Cabana Changing Practice Patterns: Practice Guidelines

5/5   Adams Dudley Changing Organizations via Feedback on Quality

5/12 Diane Rittenhouse  Restructuring Organizations: Medical Homes

5/19   Helen Lipton Redesigning Benefits Structures: Drug Formularies

5/26   Molly Cooke Influencing Providers via Professional Societies

6/2   Chris Millet Pay for Performance   

COURSE REQUIREMENTS

• SHOW UP, DO READINGS, ENGAGE

• THINK ABOUT WAYS TO APPLY T2 SYSTEMS INTERVENTIONS TO YOUR AREA OF EXPERTISE

• DEVELOP ONE LOI/BRIEF PROPOSAL

Introduction: PART 2Introduction: PART 2

WHAT IS TRANSLATIONAL

RESEARCH?

T1 and T2 TRANSLATIONT1 and T2 TRANSLATION

Translation as Institutional Initiative

NIH Roadmap for Medical Research

Re-engineering the clinical research enterprise

DEFINING THE PROBLEM• “Silos:” Institutional and programmatic boundaries had

created fragmented research efforts, training programs and resources that would be effective if integrated.

• “Fragmentation:” The lack of centralized infrastructure has been a huge barrier to conducting clinical and translational research.

• “Balance:” Declining interest in patient-oriented research

• “Lack of collaboration:” Need for a team approach—breaking down barriers between basic and clinical scientists

Two Spheres of Translational Research

T1 “Roadblock”

-to harness knowledge from basic sciences to produce new drugs, devises and treatment options

-to transfer new understanding on diseases mechanisms gained in the laboratory into the development of new methods for diagnosis, therapy and prevention

• T2 “Roadblock”-ensuring that new treatments

and research knowledge actually reach the patients or populations for whom they are intended and are implemented correctly

-helping clinicians and patients make more informed choices, providing reminders and point-of-care decision support tools, and strengthening the patient-clinician relationship

Two Spheres of Translational Research

T1Research methods

- molecular biology- genetics- basic sciences- clinical sciences

Settings- strong laboratories- cutting edge technology

Challenges-biological & technological complexities- trial recruitment- regulatory concerns

T2Research Methods

-”implementation science” & org theory-evaluation studies- clinical epidemiology-communication theory- public policy-health services research

Settings- community and practice-based settings- population-based interventions

Challenges-organizational inertia-resource constraints-inability to control “noise”-power relations/vested interests

Translational Research InfrastructureNIH Clinical and Translational Science Awards

• 24 CTSIs (“academic homes”) already formed• Goal of 60 CTSIs by 2012• Budget of $500 million per year

Multi-Stakeholder Translational Research Programs

European Commission – program centerpiece

Two new journals: Translational MedicineJournal of Translational Medicine

THE PROMISE OF T2 TRANSLATION

• It could ultimately save more lives than T1

• T2 could make the health care system perform better in delivering what we have

• Greater fidelity in delivering aspirin to eligible patients could prevent more strikes that developing more potent antiplatelet agents

• Increasing patient safety, access and equity could do more to improve health than a new imaging device or class of drugs.

Introduction PART 2Introduction PART 2

HOW DO WE UNDERSTAND T2 IMPLEMENTATION

AT THE SYSTEMS LEVEL?

Organizational Environments

Intra- VERSUS Inter- Organizational Theory

Environment supplies resources to organizations (money, people, power, legitimacy)

Organizations are focused on survival not efficiency

Resource Dependency: Power flows to places within the organization that attract resources

Organizational Fields:One Way to Think about Environments

To ensure mutual survival, organizations form a social order or “organizational field”

Characteristics of Organizational Fields

• A power structure

• Shared goals, rules and assumptions

• Meaningful roles

• Government organizations are part of the field

The HEALTH CARE SYSTEM

AS AN

ORGANIZATIONAL FIELD

The Health Care System

Large Employers

Government Insurance Plans

(e.g., Medicare, Medicaid)

Managed Health Plans(e.g., HMOs, PPOs)

Hospital Corporations“Providers” and

“Consumers”

SUPPLIERS

BUYERS

Who has power?

LARGE BUYERS:

EMPLOYERS AND GOVERNMENT PURCHASERS

Government Organizations Play Different Roles

• Government as “venture capitalist”

• Rule maker and enforcer (e.g., FTC, courts)

• Largest Buyer in the market (e.g., Medicare, Medicaid)

Other Players in the Field

• Health Plans (providers + insurers)• Organized Provider Groups (AMA, ANA)• Quasi-governmental agencies (NCQA)• Supplier corporations (Pharma)• Consumer groups (AARP, Unions)• Educational institutions (UCSF)• Science institutions (NIH, RWJF)

What is a Health Plan?

provider + insurance = MANAGEDgroup plan HEALTH

PLAN

CASE STUDY: CASE STUDY:

The U.S. Health Care The U.S. Health Care Transformation (1965-1995)Transformation (1965-1995)

The reorganization of a The reorganization of a fieldfield

Dr. Marcus Welby: WHAT HAPPENED?

The Health Care Transformation

Before 1965

• Doctor-controlled order

• Protect doctor-patient

relationship

• Independent, nonprofit organizations

• Non-interference in medical affairs

After 1980

• Buyer-dominated market

• Increase efficiency and cost accountability

• For-profit medical corporations

• Stimulates competition and steers the market

System ofPower

Shared Goals

Roles forOrganizations

Government’sRole

Summary

• T2 has at least two parts: intra- and inter-organizational change strategies

• Sociology of Organizational Environments provides a frame for understanding systems

• Key aspects of systems: power structure, shared goals, roles for organizations and government